MEDICARE: KENYATTA EVANS-SNULLIGAN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SA2200X	Adult Health Clinical Nurse Specialist	041361698	IL
2	364SA2200X	Adult Health Clinical Nurse Specialist	209-008944	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041361698	OTHER	IL	IL STATE LICENSE

General Provider Information

NPI Number	:	1194008425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYATTA EVANS-SNULLIGAN NP

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 W CERMAK RD
Second Line	:	CUITE C119
City	:	CHICAGO
State	:	IL
Zip	:	60608-4500
Country	:	US
Telephone Number	:	312-243-2223
Fax Number	:	312-243-2227

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	02/28/2025

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